A 48-year-old man comes to the emergency department with several days of headache, photophobia, nausea, and vomiting. He has also had decreased hearing in the left ear and occasional vision floaters for the past week. The patient has no earache, tinnitus, or vertigo. He was treated for gonorrhea 6 months ago with a single antibiotic injection. He uses intravenous drugs and reports having unprotected sex with multiple partners. The patient does not use tobacco or alcohol and has not traveled recently. His temperature is 37.2 C (99 F), blood pressure is 122/68 mm Hg, and pulse is 92/min. He has bilateral eye irritation and a generalized maculopapular rash, as shown in the exhibit. Multiple, nontender cervical and inguinal lymph nodes are palpable. There is sensorineural hearing loss in the left ear and neck stiffness. Cardiopulmonary examination is normal. The abdomen is soft and nontender. The motor examination is symmetric, and reflexes are 2+ bilaterally throughout the upper and lower extremities. Which of the following is the most likely diagnosis?

Question

A 48-year-old man comes to the emergency department with several days of headache, photophobia, nausea, and vomiting.  He has also had decreased hearing in the left ear and occasional vision floaters for the past week.  The patient has no earache, tinnitus, or vertigo.  He was treated for gonorrhea 6 months ago with a single antibiotic injection.  He uses intravenous drugs and reports having unprotected sex with multiple partners.  The patient does not use tobacco or alcohol and has not traveled recently.  His temperature is 37.2 C (99 F), blood pressure is 122/68 mm Hg, and pulse is 92/min.  He has bilateral eye irritation and a generalized maculopapular rash, as shown in the exhibit.  Multiple, nontender cervical and inguinal lymph nodes are palpable.  There is sensorineural hearing loss in the left ear and neck stiffness.  Cardiopulmonary examination is normal.  The abdomen is soft and nontender.  The motor examination is symmetric, and reflexes are 2+ bilaterally throughout the upper and lower extremities.  Which of the following is the most likely diagnosis?

Quizplus · Accepted Answer

Explanation: 11ec2b69_bfc4_8302_8f63_d711399a7bb9_MD0005_00 This patient with high-risk sexual behavior (unprotected sex with multiple partners, history of gonorrhea) has signs and symptoms of meningitis (headache, photophobia, neck stiffness) that have developed subacutely and are accompanied by floaters, eye irritation, and hearing loss. These features are suggestive of symptomatic meningitis, ocular syphilis, and otosyphilis and are likely manifestations of early neurosyphilis, which occurs most commonly during the secondary stage of syphilis (as indicated by the generalized maculopapular rash and lymphadenopathy). Neurosyphilis can occur at any time following Treponema pallidum infection. The early stages usually affect the cerebrospinal fluid (CSF), meninges, and vasculature and are not considered manifestations of tertiary syphilis; the late forms more commonly cause disease of the spinal cord (eg, tabes dorsalis) and brain parenchyma and are considered manifestations of tertiary syphilis. Patients with syphilitic meningitis are usually not as sick as those with bacterial meningitis and frequently have a prodrome several days prior to meningitic symptoms. A CSF-VDRL test is almost universally reactive. Ocular syphilis can present as impaired vision with posterior uveitis, retinitis, or optic neuritis. Cranial neuropathies, especially of the optic, facial, or auditory nerves, can occur. Otosyphilis may also present with tinnitus. (Choices A and C) Both acute HIV infection and infectious mononucleosis can present with fever, lymphadenopathy, rash, and neurologic symptoms. However, cranial nerve palsies and visual and auditory symptoms are not typical of acute HIV. Neurologic symptoms of mononucleosis (eg, meningitis, cranial neuropathies) are rare and usually develop 2-4 weeks after other acute symptoms. (Choice B) Disseminated gonococcemia presents as either a combination of rash with tenosynovitis and non-purulent polyarthralgia or lone purulent polyarthritis. (Choice D) Meningococcal infections may present with rash and meningitis but would progress rapidly (usually over a period of hours rather than days) to severe and life-threatening meningitis. Educational objective: Early neurosyphilis may present with symptomatic meningitis, ocular syphilis, and otosyphilis. Patients with syphilitic meningitis are usually not as sick as those with bacterial meningitis and frequently have a prodrome several days preceding presentation of meningitic symptoms. Cranial neuropathies, especially of the optic, facial, or auditory nerves, can occur. References: Canadian Public Health Laboratory Network laboratory guidelines for the diagnosis of neurosyphilis in Canada. (http://www.ncbi.nlm.nih.gov/pubmed/25798161) Neurosyphilis in the modern era. (http://www.ncbi.nlm.nih.gov/pubmed/15548491)

A 48-Year-Old Man Comes to the Emergency Department with Several